CASE REPORT
Endovascular Approach to Acute Hemorrhage in Locally Advanced Breast Cancer Stacy Ugras, MD,* Mary L. Gemignani, MD,* Peter H. Connolly, MD,† and David J. Finley, MD‡ *Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; †Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York; ‡Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
n Abstract: We report a case of a woman with recurrent axillary fungating breast cancer who developed catastrophic hemorrhage from tumor erosion of her axillary artery. This was treated successfully with endovascular placement of a covered arterial stent. We discuss the suitability of endovascular therapy for patients with advanced malignancy given its lower morbidity in this population with decreased life expectancy. n Key Words: breast cancer, endovascular procedures/stents, hemorrhage
A
cute catastrophic hemorrhage from arterial erosion by malignant fungating wounds is an uncommon but serious complication. Historically, acute tumor-induced hemorrhage was treated using open surgical technique with high morbidity. To our knowledge, there is only one other report in the literature in which tumor-induced axillary arterial hemorrhage was treated using an endovascular approach (1). The patient is a 49-year-old woman with T2NM0 estrogen receptor-positive, progesterone receptor-negative, and Her2-neu-negative locally advanced left breast cancer. She underwent neo-adjuvant chemotherapy with Adriamycin/Cytoxan and Taxol followed by breast-conserving surgery and axillary lymphadenectomy. The pathology from this initial operation revealed minimal treatment response in the primary tumor and 2/12 involved axillary lymph nodes. She received endocrine therapy postoperatively and radiation therapy to her breast as well as her axillary and supraclavicular lymph node basins. Two months after completion of treatment, she presented with a recurrent left axillary tumor mass. This was managed with excision and level
Address correspondence and reprint requests to: David J. Finley, MD, Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA, or e-mail: [email protected] DOI: 10.1111/tbj.12373 © 2015 Wiley Periodicals, Inc., 1075-122X/15 The Breast Journal, Volume 21 Number 2, 2015 189–191
3 axillary lymphadenectomy in which 4/6 lymph nodes harbored metastatic breast cancer, with the largest mass in her axilla measuring 3 cm. Within 3 months, she developed progressive disease presenting as axillary nodularity and skin breakdown. Multiple systemic therapy regimens were administered over the course of 5 months; these were ineffective, and she developed a fungating axillary tumor that invaded her chest wall. She received additional palliative radiotherapy to the axilla and chest wall with minimal effect. Subsequently, the tumor in her axilla progressed posteriorly from her chest wall and directly invaded the spine, requiring a laminectomy for palliation. Over the course of her disease, she had multiple wound infections requiring debridement. She developed upper extremity lymphedema and contracture of her shoulder limiting her range of motion to 30 degrees of abduction. Imaging revealed that the tumor mass invaded her chest wall and abutted her left axillary artery (Fig. 1). Two years after her initial operation, she developed high-volume hemorrhage from her left axillary wound. Bleeding ceased by the time she presented to her local emergency department, where her hemoglobin was 5.3 g/dL and she was transfused packed red blood cells (pRBCs) and transferred to a tertiary care cancer center. The next morning her Hb was 7.1 g/dL and she was hemodynamically stable until she developed
190 • ugras et al.
Figure 1. Computed tomography image of chest wall mass abutting axillary artery (arrow).
massive hemorrhage from her axilla 24 hours after the initial bleeding episode. She rapidly developed hemorrhagic shock and respiratory failure. She was intubated and resuscitated with 8 units of pRBCs, 2 units of fresh frozen plasma, and 1 unit of platelets. She was taken emergently to the operating room while bleeding was partially controlled with manual pressure within the axillary wound. Local wound exploration was limited secondary to shoulder immobility, and there was no opportunity to visualize the bleeding vessel or perform primary repair through the wound. A sponge stick was used to apply local pressure to the area deep in her axilla which was actively bleeding, and was successful in controlling the hemorrhage. Next, arterial access was obtained in the left brachial artery via a retrograde approach with a six French introducer sheath and using percutaneous Seldinger technique. Angiography revealed no active extravasation but did suggest an intimal disruption, which was the origin of a probable pseudoaneurysm of the axillary artery (Fig. 2). Given the limited surgical exposure, the decision was made to place a covered stent across this defect. A 6 mm diameter by 5 cm long Viabhan (Gore, Newark, DE) covered stent was placed across the defect under fluoroscopy. Final angiography showed good positioning (Fig. 3). The patient was admitted to the surgical intensive care unit where she remained hemodynamically stable; she was extubated later that day, requiring no further blood transfusion. She regained baseline motor function in her upper extremity. She was transferred to an inpatient unit on postoperative day 2 and was discharged to hospice on postoperative day 11. The patient expired 1 month later. Neither recurrent bleeding nor stent occlusion occurred.
Figure 2. Angiogram revealing pseudoaneurysm of axillary artery (arrow).
Figure 3. Angiogram revealing axillary arterial stent (arrows).
COMMENT Bleeding complicates up to 10% of patients with advanced malignancy. It can result from direct invasion and damage of blood vessels by the tumor or from systemic disorders of coagulopathy. Local invasion of blood vessels can cause ongoing low-volume hemorrhage or episodic major hemorrhage (2). Often, underlying infection of the tumor mass causes damage to the blood vessel wall leading to pseudoaneurysm formation. Management includes the use of hemostatic dressings, intravascular hemostatic agents, and radiotherapy, with more aggressive therapy being reserved for cases of severe bleeding. This includes surgical therapy with vessel ligation or tissue resection as well as endovascular measures, including placement of transcutaneous arterial embolization balloons or stents, as in this case (3). Surgical control in the current case would have involved a combination of supraclavicular and
Acute Hemorrhage in Breast Cancer • 191
infraclavicular incisions, median sternotomy, or thoracotomy with extensive dissection resulting in significant perioperative risk. In the setting of surgical treatment of subclavian and axillary arterial injuries, a postoperative complication rate of 24% was reported by Kalakuntla et al. (4). Complications include injury to the vagus, recurrent laryngeal, and phrenic nerves as well as to the innominate vein. Other studies report a mortality rate of 5–30% (5,6). The majority of the experience of endovascular treatment of axillary arterial injuries has occurred in the trauma setting. Xenos et al. reported on a series of seven patients with traumatic injuries to the subclavian or axillary artery that underwent endovascular repair using a Wallgraft endoprosthesis (7). Compared to 16 patients treated with open repair, those undergoing endovascular repair had significantly shorter operative time and less blood loss. Another advantage includes the potential to avoid general anesthesia by performing endovascular therapy under local anesthesia. Risks of endovascular therapy include issues with long-term patency secondary to stenosis, decreased graft durability, migration, infection, and endoleak. Short-term results of endovascular repair have been reported and are encouraging; however, long-term durability has not been assessed. This is, however, less concerning in the terminal cancer patient with limited longevity. To our knowledge, there has been only one case report of breast cancer causing axillary arterial hemorrhage that was treated with an endovascular approach (1). The patient had inflammatory cancer that eroded the axillary artery, resulting in a likely infected pseudoaneurysm that caused life-threatening hemorrhage. After resuscitation, an endovascular stent was successfully placed in the interventional radiology unit. Given the success of endovascular treatment in this case and in our report, we are more likely to recommend this treatment to be performed in similar settings. We suggest the optimal setting for endovascular treatment in
these acute settings is in the operating room where rapid conversion into open surgery is possible if needed, and more support is available. Our case highlights that endovascular technique can be used to treat life-threatening arterial hemorrhage from fungating tumor wounds while minimizing morbidity to the terminal cancer patient. Such an approach can also be applied in the prophylactic setting to prevent catastrophic hemorrhage from tumor erosion of arteries. The awareness of a high-risk lesion can also provide the opportunity to discuss palliative goals so that therapeutic measures are in line with goals of therapy.
FUNDING The authors report no funding disclosures.
CONFLICTS OF INTEREST The authors disclosures.
report
no
conflict
of
interest
REFERENCES 1. Mroczkowski P, Eder F, Effenberger O, Halloul Z. Endovascular treatment of tumor-induced axillary artery hemorrhage. Vasa 2007;36:50–2. 2. Belt RJ, Leite C, Haas CD, Stephens RL. Incidence of hemorrhagic complications in patients with cancer. JAMA 1978;239:2571–4. 3. Pereira J, Phan T. Management of bleeding in patients with advanced cancer. Oncologist 2004;9:561–70. 4. Kalakuntla V, Patel V, Tagoe A, Weaver W. Six-year experience with management of subclavian artery injuries. Am Surg 2000;66:927–30. 5. Demetriades D, Chahwan S, Gomez H, et al. Penetrating injuries to the subclavian and axillary vessels. J Am Coll Surg 1999;188:290–5. 6. Rich NM, Hobson RW, Jarstfer BS, Geer TM. Subclavian artery trauma. J Trauma 1973;13:485–96. 7. Xenos ES, Freeman M, Stevens S, Cassada D, Pacanowski J, Goldman M. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg 2003;38:451–4.
Copyright of Breast Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Endovascular Approach to Acute Hemorrhage in Locally Advanced Breast Cancer Stacy Ugras, MD,* Mary L. Gemignani, MD,* Peter H. Connolly, MD,† and David J. Finley, MD‡ *Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; †Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York; ‡Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
n Abstract: We report a case of a woman with recurrent axillary fungating breast cancer who developed catastrophic hemorrhage from tumor erosion of her axillary artery. This was treated successfully with endovascular placement of a covered arterial stent. We discuss the suitability of endovascular therapy for patients with advanced malignancy given its lower morbidity in this population with decreased life expectancy. n Key Words: breast cancer, endovascular procedures/stents, hemorrhage
A
cute catastrophic hemorrhage from arterial erosion by malignant fungating wounds is an uncommon but serious complication. Historically, acute tumor-induced hemorrhage was treated using open surgical technique with high morbidity. To our knowledge, there is only one other report in the literature in which tumor-induced axillary arterial hemorrhage was treated using an endovascular approach (1). The patient is a 49-year-old woman with T2NM0 estrogen receptor-positive, progesterone receptor-negative, and Her2-neu-negative locally advanced left breast cancer. She underwent neo-adjuvant chemotherapy with Adriamycin/Cytoxan and Taxol followed by breast-conserving surgery and axillary lymphadenectomy. The pathology from this initial operation revealed minimal treatment response in the primary tumor and 2/12 involved axillary lymph nodes. She received endocrine therapy postoperatively and radiation therapy to her breast as well as her axillary and supraclavicular lymph node basins. Two months after completion of treatment, she presented with a recurrent left axillary tumor mass. This was managed with excision and level
Address correspondence and reprint requests to: David J. Finley, MD, Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA, or e-mail: [email protected] DOI: 10.1111/tbj.12373 © 2015 Wiley Periodicals, Inc., 1075-122X/15 The Breast Journal, Volume 21 Number 2, 2015 189–191
3 axillary lymphadenectomy in which 4/6 lymph nodes harbored metastatic breast cancer, with the largest mass in her axilla measuring 3 cm. Within 3 months, she developed progressive disease presenting as axillary nodularity and skin breakdown. Multiple systemic therapy regimens were administered over the course of 5 months; these were ineffective, and she developed a fungating axillary tumor that invaded her chest wall. She received additional palliative radiotherapy to the axilla and chest wall with minimal effect. Subsequently, the tumor in her axilla progressed posteriorly from her chest wall and directly invaded the spine, requiring a laminectomy for palliation. Over the course of her disease, she had multiple wound infections requiring debridement. She developed upper extremity lymphedema and contracture of her shoulder limiting her range of motion to 30 degrees of abduction. Imaging revealed that the tumor mass invaded her chest wall and abutted her left axillary artery (Fig. 1). Two years after her initial operation, she developed high-volume hemorrhage from her left axillary wound. Bleeding ceased by the time she presented to her local emergency department, where her hemoglobin was 5.3 g/dL and she was transfused packed red blood cells (pRBCs) and transferred to a tertiary care cancer center. The next morning her Hb was 7.1 g/dL and she was hemodynamically stable until she developed
190 • ugras et al.
Figure 1. Computed tomography image of chest wall mass abutting axillary artery (arrow).
massive hemorrhage from her axilla 24 hours after the initial bleeding episode. She rapidly developed hemorrhagic shock and respiratory failure. She was intubated and resuscitated with 8 units of pRBCs, 2 units of fresh frozen plasma, and 1 unit of platelets. She was taken emergently to the operating room while bleeding was partially controlled with manual pressure within the axillary wound. Local wound exploration was limited secondary to shoulder immobility, and there was no opportunity to visualize the bleeding vessel or perform primary repair through the wound. A sponge stick was used to apply local pressure to the area deep in her axilla which was actively bleeding, and was successful in controlling the hemorrhage. Next, arterial access was obtained in the left brachial artery via a retrograde approach with a six French introducer sheath and using percutaneous Seldinger technique. Angiography revealed no active extravasation but did suggest an intimal disruption, which was the origin of a probable pseudoaneurysm of the axillary artery (Fig. 2). Given the limited surgical exposure, the decision was made to place a covered stent across this defect. A 6 mm diameter by 5 cm long Viabhan (Gore, Newark, DE) covered stent was placed across the defect under fluoroscopy. Final angiography showed good positioning (Fig. 3). The patient was admitted to the surgical intensive care unit where she remained hemodynamically stable; she was extubated later that day, requiring no further blood transfusion. She regained baseline motor function in her upper extremity. She was transferred to an inpatient unit on postoperative day 2 and was discharged to hospice on postoperative day 11. The patient expired 1 month later. Neither recurrent bleeding nor stent occlusion occurred.
Figure 2. Angiogram revealing pseudoaneurysm of axillary artery (arrow).
Figure 3. Angiogram revealing axillary arterial stent (arrows).
COMMENT Bleeding complicates up to 10% of patients with advanced malignancy. It can result from direct invasion and damage of blood vessels by the tumor or from systemic disorders of coagulopathy. Local invasion of blood vessels can cause ongoing low-volume hemorrhage or episodic major hemorrhage (2). Often, underlying infection of the tumor mass causes damage to the blood vessel wall leading to pseudoaneurysm formation. Management includes the use of hemostatic dressings, intravascular hemostatic agents, and radiotherapy, with more aggressive therapy being reserved for cases of severe bleeding. This includes surgical therapy with vessel ligation or tissue resection as well as endovascular measures, including placement of transcutaneous arterial embolization balloons or stents, as in this case (3). Surgical control in the current case would have involved a combination of supraclavicular and
Acute Hemorrhage in Breast Cancer • 191
infraclavicular incisions, median sternotomy, or thoracotomy with extensive dissection resulting in significant perioperative risk. In the setting of surgical treatment of subclavian and axillary arterial injuries, a postoperative complication rate of 24% was reported by Kalakuntla et al. (4). Complications include injury to the vagus, recurrent laryngeal, and phrenic nerves as well as to the innominate vein. Other studies report a mortality rate of 5–30% (5,6). The majority of the experience of endovascular treatment of axillary arterial injuries has occurred in the trauma setting. Xenos et al. reported on a series of seven patients with traumatic injuries to the subclavian or axillary artery that underwent endovascular repair using a Wallgraft endoprosthesis (7). Compared to 16 patients treated with open repair, those undergoing endovascular repair had significantly shorter operative time and less blood loss. Another advantage includes the potential to avoid general anesthesia by performing endovascular therapy under local anesthesia. Risks of endovascular therapy include issues with long-term patency secondary to stenosis, decreased graft durability, migration, infection, and endoleak. Short-term results of endovascular repair have been reported and are encouraging; however, long-term durability has not been assessed. This is, however, less concerning in the terminal cancer patient with limited longevity. To our knowledge, there has been only one case report of breast cancer causing axillary arterial hemorrhage that was treated with an endovascular approach (1). The patient had inflammatory cancer that eroded the axillary artery, resulting in a likely infected pseudoaneurysm that caused life-threatening hemorrhage. After resuscitation, an endovascular stent was successfully placed in the interventional radiology unit. Given the success of endovascular treatment in this case and in our report, we are more likely to recommend this treatment to be performed in similar settings. We suggest the optimal setting for endovascular treatment in
these acute settings is in the operating room where rapid conversion into open surgery is possible if needed, and more support is available. Our case highlights that endovascular technique can be used to treat life-threatening arterial hemorrhage from fungating tumor wounds while minimizing morbidity to the terminal cancer patient. Such an approach can also be applied in the prophylactic setting to prevent catastrophic hemorrhage from tumor erosion of arteries. The awareness of a high-risk lesion can also provide the opportunity to discuss palliative goals so that therapeutic measures are in line with goals of therapy.
FUNDING The authors report no funding disclosures.
CONFLICTS OF INTEREST The authors disclosures.
report
no
conflict
of
interest
REFERENCES 1. Mroczkowski P, Eder F, Effenberger O, Halloul Z. Endovascular treatment of tumor-induced axillary artery hemorrhage. Vasa 2007;36:50–2. 2. Belt RJ, Leite C, Haas CD, Stephens RL. Incidence of hemorrhagic complications in patients with cancer. JAMA 1978;239:2571–4. 3. Pereira J, Phan T. Management of bleeding in patients with advanced cancer. Oncologist 2004;9:561–70. 4. Kalakuntla V, Patel V, Tagoe A, Weaver W. Six-year experience with management of subclavian artery injuries. Am Surg 2000;66:927–30. 5. Demetriades D, Chahwan S, Gomez H, et al. Penetrating injuries to the subclavian and axillary vessels. J Am Coll Surg 1999;188:290–5. 6. Rich NM, Hobson RW, Jarstfer BS, Geer TM. Subclavian artery trauma. J Trauma 1973;13:485–96. 7. Xenos ES, Freeman M, Stevens S, Cassada D, Pacanowski J, Goldman M. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg 2003;38:451–4.
Copyright of Breast Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
